Association between Moral Distress and Burnout Syndrome in university-hospital nurses

Abstract Objective: to analyze the association between moral distress and Burnout Syndrome among nurses in a university hospital. Method: descriptive, analytical study conducted with 269 nurses working in a university hospital located in Rio Grande do Sul, Brazil. Data were collected in person in 2019 by previously trained collectors. A sociodemographic and employment questionnaire, the Brazilian Scale of Moral Distress in Nurses and the Maslach Burnout Inventory were applied. Descriptive and analytical statistical analysis was used. Results: an association was identified between moral distress intensity and frequency and its dimensions with Burnout Syndrome and its dimensions. Nurses with low professional achievement and high emotional exhaustion showed a higher prevalence of moral distress. Conclusion: an association between moral distress and Burnout Syndrome, as well as between their dimensions, was evidenced. The results suggest the need to investigate urgent interventions to mitigate the situations and manifestations of moral distress and Burnout Syndrome by developing strategies for workers’ health.


Introduction
Nursing work is considered essential due to its performance in various health care settings. The nursing work process demands concentration and effort from workers, especially in hospitals, where a heavy workload is observed, which leads to illness (1) , such as physical and psychological fatigue, in addition to high stress levels (2) .
These aspects may be related to situations in which nurses are faced with ethical issues that eventually cause conflicts and interfere in the quality of work activities, since they result in morally unsatisfactory responses (3) .
Situations such as these can cause moral distress (MD), which occurs when a nurse feels unable to perform what he/she considers to be ethically correct, that is, he/she identifies what is appropriate to do, but realizes that he/ she is unable to undertake such an action (4) . Furthermore, MD is defined as a psychological response to morally challenging situations, such as those of embarrassment and moral conflict (3) .
In Brazil, MD has been analyzed in different fields of nursing practice. In some hospital studies, low to medium levels of MD were found (5)(6) . Recent studies have reported a moderate level of MD in hospital nurses (7) , which is mainly related to the work environment, such as the lack of resources and the lack of communication among professionals (8) . These aspects can threaten nurses' health and well-being and lead them to illness, thus hindering their ability to provide safe, timely, efficient and peoplecentered care. In these cases, there may be implications for the professional, such as the development of Burnout

Syndrome (BS).
BS is defined as a psychological syndrome characterized by three dimensions: emotional exhaustion, depersonalization and low professional achievement (9) . This topic has been investigated in health services, where health care professionals are exposed to high levels of stress at work, showing moderate to severe BS (10) . Another study reports that the workload may be related to the high risk for developing BS among nurses (11) .
The relationship between MD and BS has been pointed out in the literature, since MD development due to ethical problems, such as difficulty in making correct decisions and the lack of resources to provide proper care to patients causes stress, whose chronicity, in turn, leads to BS among nurses. Recent studies have reported a significant and positive relationship between MD and SB, showing that MD is consistently related to emotional exhaustion and depersonalization (3,12) . The main aspects of the work environment that are related to MD and BS are observed, such as: therapeutic obstinacy, disrespect for patients' rights, nurses' moral harassment, the work team's incompetence, insufficient and/or inadequate communication, power relations, poor working conditions, work overload, (dis)satisfaction and intention to resign from one's job (13) .
These situations, which are often found in daily work routine, raise concerns regarding the development of standards and resolutive strategies to promote these professionals' health and quality of life. This study contributes to research and to nursing practice by identifying the association between two illness variables, which are relevant to the hospital setting and can interfere with nurses' health.
Given the above, the hypothesis is: Moral distress is associated with Burnout Syndrome among nurses at a university hospital. And, in order to verify it, the following objective was presented: to analyze the association between moral distress and Burnout Syndrome among nurses in a university hospital.

Study design
This is a descriptive, analytical study guided by the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) tool.

Research setting
The study was developed at a university hospital located in Rio Grande do Sul, Brazil. The institution provides 100% of its services through the Unified Health System and is characterized as a tertiary-level, general, public teaching hospital. The units that participated in this study were the: the adults' and pediatric emergency department, internal medicine and surgery clinic, obstetric center and gynecological unit, intensive care units (adult, pediatric, neonatal and cardiology), outpatient clinic, hemato-oncology sector, pediatrics, psychiatry, surgery room, materials and sterilization center, recovery room, cardiovascular service and administrative sectors.

Population, selection criteria and sample definition
All the 303 nurses working in the hospital units were invited to participate in the study. The inclusion criterion adopted was: being a nurse who had been working at

Instruments used
The data collection instrument consisted of a sociodemographic and employment questionnaire,  (15) . MBI was developed in 1981 (9) and adapted for the Brazilian culture in 1995 (16) , that is, the instrument has been validated for Brazil and the authors were asked to authorize its use for nurses in a hospital setting, showing a reliability level of 0.89. This instrument evaluates BS according to three dimensions: emotional exhaustion, depersonalization and low professional achievement. They were also given the Informed Consent Form (ICF), which was signed by the participants and the researcher, with a copy for each one of those involved.
This procedure ensured them the right to withdraw from participation at any time, without public disclosure of their information.

Data analyses
Data were organized by the Epinfo ® software, version 6.4, with two independent data entries and a check for     significance level was adopted (17)(18) .
As a form of analyzing the regression model's quality, the multicollinearity indicators were examined by means of the linear regression procedure, tolerance measure and the variance inflation factor (VIF), through which no multicollinearity was registered, due to the fact that the tolerance and VIF values fell within levels higher than 0.1 and lower than 5, respectively, thus suggesting the model's adequacy (18) .

Ethical aspects
All ethical precepts of research involving human beings, as established in Resolution 466/12 (19) , were observed. This study is part of a matrix project entitled

Results
The study participants were 269 nurses, of whom 88.1% (n=237) were females, 69.9% (n=188) had more than 10 years' experience and 69.5% (n=187) had worked at the institution for longer than four years.
Among the six factors in the EDME-Br scale, moderate levels of MD intensity and frequency were observed for items of three factors: "Working conditions" -item (10) "Acknowledging that the permanent equipment/materials available are insufficient" -frequency and intensity:
There was an association between MD frequency, the emotional-exhaustion and depersonalization dimensions and low professional accomplishment, in which nurses with high emotional exhaustion, high depersonalization and low professional achievement showed higher MD frequency for both the general scale and the six factors.
In order to evaluate the associations found between MD, BS and the sociodemographic and employment variables, the prevalence and the raw and adjusted associations by Poisson Regression are shown in Table 3.
There was an association between MD intensity and the emotional-exhaustion, depersonalization and lowprofessional-achievement dimensions, in which the nurses with high emotional exhaustion and high depersonalization showed higher MD intensity for both the general scale and the six factors. On the other hand, the nurses with low professional achievement and burnout showed higher MD intensity in Factor 1 -Acknowledgement, power and professional identity, in Factor 2 -Safe and qualified care, in Factor 6 -Work teams and in the general MD scale.

The association between MD frequency and BS is
shown in Table 2.   consequently, being an MD predictor. These findings express the occurrence of MD in work environments (5,15) .
The factor "Safe and qualified care" indicated problems regarding insufficient access to the service and educational actions, inadequate embracement and care provision impairment, unmet demands for care continuity and lack of resolutivity of health care actions. Professionals are prone to develop symptoms of emotional and physical exhaustion due to the work environment that involves complex demands, patient care expectations, and few resources available to provide proper care (28) .
The factor "Work teams" presented problems concerning the insufficient number of professionals to meet the demand, in addition to work overload and unprepared doctors. In agreement with these findings, a Brazilian study showed similar results, since this factor showed higher medians for MD intensity and frequency when compared to the others, as the insufficient number of professionals on a team causes work overload and, consequently, there cannot be proper patient care (15) .
This study showed an association between MD intensity (P < 0.001) and frequency (P < 0.001) and the BS dimensions. In intensive care units, nurses showed a medium-to-high degree of emotional distress and depersonalization when compared to those working in inpatient units (29) , which may be associated with the nurses' exposure to intense working hours, feelings of demotivation to perform tasks and difficulties to relate with colleagues and patients, thus leading to higher MD intensity (30) . Regarding the relationship between the frequency of MD situations and the BS dimensions, it is shown that, from this perspective, studies suggest the need for resolute measures to mitigate illness among nurses (31) as well as its interference with the quality of the care provided (32) .
As reported in the literature, regarding nurses working in hospitals and primary care in Punta Arenas, almost half of these health professionals had low or medium levels of professional achievement (33) . In a study, it was possible to observe that professional accomplishment negatively influences MD, showing that the higher the professional achievement, the lower the MD (34) . Low professional accomplishment at work can be described as a feeling that little has been achieved, causing a reduction in motivation and in the feeling of accomplishment (30) .
A limitation to this study is the fact that it was conducted in only one hospital, which renders it difficult to generalize its results.
However, it contributes to the advancement of knowledge in the nursing field by evaluating the association of MD frequency and intensity with the dimensions of BS.
Its results suggest the need for developing actions that

Discussion
This study showed an association between MD and BS as well as between their respective dimensions, finding that high emotional exhaustion, high depersonalization, and low professional achievement are related to decisionsharing among nurses and their colleagues, in addition to moral deliberation in difficult situations, which compromises the worker's health (3) .
In this regard, considering the regression model, it was observed that the highest MD prevalence levels were among nurses on the morning shift, with an employment relationship under RJU, an intention to resign, high emotional exhaustion and low professional achievement.
Nurses working the morning shift had a higher MD prevalence due to work overload resulting from the various routines occurring on this shift, such as baths, dressings, medical visits, in addition to internal interferences and clinical complications (20) . Professionals with an employment regime under RJU had a higher MD prevalence due to the lack of stability that such a contract poses on employees (21) . Corroborating these facts, it was observed in the literature that, despite the stability that the job provides, professionals under RJU contracts are more likely to resign from their jobs due to work overload and, consequently, to their experiencing more psychological distress and emotional exhaustion (22) .
The intention to resign is justified by the higher MD prevalence and some factors may interfere, such as: long working hours, low wages, and difficulty in relating to other professionals. Thus, it is perceived that nurses who work more than 40 hours per week are more likely to leave their jobs when compared to those who work 40 hours per week or less (23) , which shows that each increase in MD frequency can double the chances of intending to resign (24) .
High emotional exhaustion among nursing professionals may be related to the severity of the patients' conditions, workload increase and shortage of human resources (25) . These professionals' work routine includes physical and emotional overload, human and material resources deficits, little recognition and lack of incentive for professional development (3) .
Low professional achievement reflects a negative self-assessment of performance and motivation to act, showing a decreased feeling of competence and productivity, thereby adversely affecting the work environment (26) . Thus, these professionals felt unable to develop tasks, being less satisfied with their jobs due to the undervaluation of their work performance (27) .

Conclusion
Based on the analysis in this study, an association was found between MD and SB, as well as between their dimensions, in which MD intensity and frequency were associated with high emotional exhaustion, high depersonalization and low professional achievement. It was also observed that nurses working the morning shift, under the single legal regime, who intended to resign from their jobs and showed low professional achievement as well as high emotional exhaustion, had a higher MD prevalence.
The findings in the present study indicate the need to investigate urgent interventions in order to mitigate the situations leading to MD and BS and their manifestations by developing strategies for workers' health. It is expected that the present study will contribute to understand and inform about the importance of MD and BS implications in workers' health, as well as in patient care.